Radiology Masterclass
OSCE presentation tips

An Objective Structured Clinical Examination (OSCE) is a common examination method for assessing skills in medical imaging at medical finals in the UK. A radiology OSCE 'station' usually involves the interpretation of a radiological image in the context of a specific clinical scenario.

For the perfect presentation of any X-ray there are several necessary elements.

1. Demonstrate a systematic approach

2. Describe and summarise the salient abnormalities

3. Link the abnormalities to the clinical scenario

4. Suggest appropriate management or further investigations

This is easier said than done, but good medical finals candidates will manage this fluently. Here's how...

Read the clinical information carefully

You are usually given some clinical information about a patient before you enter the OSCE station. This information should be kept at the forefront of your mind throughout the station. You will need it later when you summarise the radiological findings.

Be aware of the scoring system

Examiners are restricted by a check list and global scoring system. They are limited to asking specific questions. See these examples - OSCE socring and check lists.

Learn your lines

You can't score points in a radiology OSCE unless you are talking. Coordinating a systematic approach and commenting as you go is difficult. The trick is to have lines prepared before you start.

The opening gambit

First, identify the patient and the type of X-ray image...

'This is a plain CHEST/ABDOMINAL radiograph of PATIENT'S NAME taken on DATE at TIME, it is a PA/AP/SUPINE/MOBILE image, and I note the side marker is correct...'

Ask to see any previous images. This will impress the examiner, even if none are available in the scenario.

Comment briefly on image quality

In the OSCE setting it would be unfair to give you an image that was technically inadequate, so don't spend too long assessing image quality. For example, if the case is a chest X-ray, don't spend too long deciding if the image is slightly rotated. This wastes valuable time. Instead you could say - 'The image is of adequate quality...' - unless it obviously isn't. If the examiner challenges the statement, you can then assess image quality more carefully. If you know you are expected to examine quality more fully, do so quickly.

Although you are unlikely to be given a chest X-ray with poor inspiration, you should always quickly note if the lungs are hyperexpanded. The quickest way to do this is to see if the hemidiaphragms are flattened, and if you are not sure, then count ribs.

Describe the obvious abnormality first

Some radiologists don't like the phrase 'obvious abnormality,' so it is best to say - 'The first abnormality to comment on is....' - and then describe it as best you can.

If you cannot see an obvious abnormality, say - 'I cannot see any abnormality at first glance...' - and then continue systematically, telling the examiner this is what you are doing - '... but looking at the image systematically...'.

Demonstrate your system

Once you have described the first abnormality, you must not assume you have finished. You should make it obvious to the examiner that you have a system for looking at the whole image by saying - 'I am now looking at the rest of the image systematically...' - and continue in an anatomical fashion.

Use appropriate 'normal' statements, such as...

'The trachea is central...'

'The hilar structures are normal...'

'The upper, middle and lower zones of the lungs are symmetrical and clear...'

'The costophrenic angles and hemidiaphragms are well-defined...'

'The heart size and contours are normal...'

'I can see no abnormality of the bones or soft tissues...'

Equivocal findings

If you are not sure whether something is abnormal, then describe what you see, saying - 'I am not sure if the... (anatomical structure)... is abnormal. It appears... (describe the structure)...' - and then move on. You can always return to an area of uncertainty if you still think it is important, once you have checked the rest of the image.

Review areas and summary

At the end, check the review areas saying - 'I am now checking the review areas...' - and, before being asked, say - 'In summary, this X-ray demonstrates evidence of...' - and in one sentence relate the imaging findings to the clinical scenario.

Clinical link and management

The clinical details you are given at the beginning are likely to be equally informative as the X-ray, if not more so. Don't forget that the OSCE is testing your ability as a day one doctor, not as a fully qualified radiologist. The best candidates will link the findings to the clinical features - 'These findings are consistent with the clinical suspicion of...'.

Good candidates will also suggest initial management or further investigations without prompting - 'In this situation I would manage the patient by...' - and suggest appropriate treatment. This step is particularly important if the findings suggest a medical emergency. Don't wait to be asked what you would do next.

The senior get out clause

Some candidates too readily defer management to seniors. Although this is entirely appropriate in many real life clinical scenarios, in the OSCE setting you should not do this too soon or, as some do, make this your only plan.

Although you will not lose marks for saying which other important people you would involve, you will be expected to know what to do yourself in the scenario given. Don't forget to mention nursing staff and other multi-disciplinary team members.

Exam etiquette

You should not ask too many questions about the image. Don't ask the examiner ...'Do you think this bit is abnormal?'... The exam is not a teaching session.

You can always ask to be reminded of the clinical scenario, and you may be given the opportunity to refer back to this before summarising your findings.

You will usually be allowed to point at the image, although it is polite to ask. Many examiners will encourage you to point, but never touch the film or monitor. Damaging precious film copies or marking a monitor with your sweaty finger will annoy the examiner. If you do touch the image by accident, apologise immediately and move on.

Your examiner

Always be polite to your examiner. Try and sound as professional as possible, and speak clearly. Introduce yourself as you enter, and say - 'Thank you'... - as you leave. If there are officials in attendance for quality assurance purposes, then remember to thank them too.

Occasionally an examiner may make a comment to lead you. This will almost certainly be helpful, and any leading comments should not be easily dismissed. Almost all examiners are on your side and want to pass you. They will have to account for any failures, and would rather not do the paper work. If they can, they will score you highly. Never argue with your examiner! If you do, the examiner may enjoy the paperwork.

An OSCE examiner should not ask questions that are not specified by the OSCE scenario, but many still do. If you are asked questions that do not refer to the scenario, keep calm and answer them as best as you can.

If things go wrong

Remember, if everything goes completely piriform, don't panic! The benefit of the OSCE exam is that you can put a bad performance behind you. Move on quickly to the next station and don't dwell on mistakes.

Listen to medical school advice

These OSCE presentation tips should only be used as a guide. Examination format varies in different medical schools, so you must be guided by information provided by your own college, and by the experience of your predecessors.

Good luck!